HESI CASE STUDY Human Immunodeficiency Virus-HIV and Tuberculosis Questions and Answers

HESI CASE STUDY Human Immunodeficiency Virus-HIV and Tuberculosis Questions and Answers How should the nurse respond? They may stay, but he needs to wear a mask What teaching should the nurse implement? Explain that the TB organism is most often spread through the air What information should the nurse provide to the UAP on infection control practices? The implementation of airborne precautions for possible TB requires a private, negative pressure room assignment What info should the nurse provide to the UAP? A fit-test HEPA mask is required for healthcare workers entering the room of someone suspected of having active TB Which tasks may the nurse delegate to the UAP? - Have the UAP tell Raymond that the specimen must be collected in the early morning - Provide client w/ 3 sterile specimen cups at his bedside - Document the time and date that each sputum specimen was collected Which activity should Raymond perform 1st upon awakening? Obtain the 1st of 3 sputum specimens for lab testing Which info should the nurse base a response about the LPN's right to refuse care for a client w/ HIV? The (L)PN may refuse to care for a client in circumstances in which risk to the nurse outweighs the nurse's responsibility to care for a client, or if the assignment conflicts w/ the nurse's ethical standards How should the nursing supervisor respond to the staff LPN who does not want to care for Raymond? "I understand you want to protect your children. Please tell me your concerns regarding caring for a client w/ HIV" Which statements by the client indicates that he understands why he is at risk for TB? - "I realize my helper T cells are diminished from HIV. Those are the cells needed to fight TB" - "I guess living in that homeless shelter increased my chances of getting TB" How should the nurse preceptor respond? That is not always true. A 5 mm induration is considered positive for a person w/ HIV How should the nurse reply? "To be most effective, HIV meds are prescribed on different schedules" How should the nurse respond? "The main purpose of these meds is to block the replication of the HIV virus" What info is important to teach the client about the use of this combo? - Rifabutin stains urine, stool, saliva, sweat, and tears reddish-orange - Liver fucntion tests should be routinely conducted and monitored -Sunscreen is recommended when exposed to sunlight while taking rifabutin Which complication of HIV is priority for the client at this time? Potential for new opportunistic infections since HIV alters the function of the immune function What info should the nurse give the UAP? Following standard precautions will minimize the exposure to blood and body fluids Which assessment finding by the nurse would be indicative of oral candidiasis, a common secondary infection in persons w/ compromised immune systems? White - yellow patches on the tongue or oral mucosa What instruction should the nurse give Raymond about the use of liquid nystatin? Place the suspension in the mouth, then swish for several minutes before swallowing To achieve the goal of improving the client nutrition, the nurse should preform which nsg intervention (s) ? - Request a dietary consultation for the client to better assess Raymond's nutritional status and food preferences - Monitor for oral candidiasis (thrush) and diarrhea Since client now has oral candidiasis (thrush), in addition to fatigue and anorexia, which food best contributes to improving Raymond's nutrition? Milk shake Which tasks should be delegated to the UAP? ( SATA ) - Weigh Raymond each morning before breakfast - Measure the urine output - Count and record the number of watery stools What is the highest priority nsg dx for Raymond? Fluid volume is decreased and client develops dehydration. Which action should the nurse take first? Take the client blood pressure to assess for postural hypotension The HCP is notified of the client's physical exam findings indicating possible dehydration and v/s, including a BP of 100/50. It is determined that Raymond could use a bolus of IV fluids. The HCP prescribed 1000 mL of NS to run over 6 hrs. the drop factor tubing set is 15 gtt/mL. How many gtts/min will the IV run 42 1000 / 360 x 15 = 41.66 gtts/min = 42 How should the nurse respond? If used correctly and consistently, latex condoms are highly effective in preventing the transmission of HIV What resource can be provided for Raymond in the event this complication occurs? Access to the services of a registered dietitian